Strategies for Safely Maintaining Surgical Volume During the COVID‐19 Pandemic: A Mixed‐Methods Study

ABSTRACT

Resuming elective surgeries that were canceled during the COVID‐19 pandemic necessitated a change to preprocedure patient preparation at a pediatric tertiary care center in middle Tennessee. We conducted a prospective, observational, mixed‐methods study to determine the effectiveness of a preprocedure COVID‐19 testing team to prevent COVID‐19–related cancellations among pediatric patients receiving planned anesthesia. The intervention involved family member and patient education and a change in health record reporting to include COVID‐19 test results. A team tasked with follow‐up reviewed test results, consulted with families, and coordinated the administration of rapid tests if necessary. We compared preimplementation and postimplementation cancellation rates in four procedural areas and found no significant difference in the cancellation or rescheduling rates (P = .89, 95% confidence interval = –4.29 to 3.09). The team‐based intervention was associated with the preservation of low procedural cancellation rates by mitigating barriers to preprocedural testing.

On March 23, 2020, Tennessee Governor Bill Lee issued a statewide executive order halting elective surgeries to conserve personal protective equipment and promote physical distancing to reduce the transmission of COVID‐19. ¹ Subsequently, Governor Lee issued a shelter‐at home order to avoid a surge of COVID‐19 infections that could dramatically reduce available hospital beds. ² When the Governor’s executive order expired ¹ and elective surgeries could resume, health system leaders at Vanderbilt University Medical Center (VUMC) instituted safety measures to determine a patient’s COVID‐19 status using preprocedure COVID‐19 testing. ³ , ⁴ In accordance with the American College of Surgeons’ recommendations for preoperative COVID‐19 testing, ³ the VUMC Incident Command Center developed a policy to ensure patients received nasopharyngeal or oropharyngeal COVID‐19 reverse transcription polymerase chain reaction (RT‐PCR) testing within 72 hours before any planned general anesthesia. Although the Infectious Diseases Society of America ⁴ recommends preprocedure COVID‐19 testing, the details of sustainably implementing testing in the perioperative setting are not well described. In May 2020, there were few asymptomatic testing sites available in Tennessee, especially in rural areas, and many sites did not offer testing for children under 24 months of age. Thus, many pediatric patients had challenges accessing asymptomatic testing. Understandably, the new requirement for preprocedure COVID‐19 testing 72 hours in advance of anesthesia, along with limited access to testing services, could lead to avoidable cancellations, delay medically necessary surgical care, and negatively influence patient outcomes. To prevent cancellations, a perioperative team approach is critical to help patients and their families access testing centers and to coordinate laboratory results reporting.

PERIOPERATIVE SURGICAL HOME MODEL AND IMPLEMENTATION

The American Society of Anesthesiologists defines the Perioperative Surgical Home (PSH) as

a patient‐centered, physician‐led, interdisciplinary, and team‐based system of coordinated care. It spans the entire surgical episode from the decision of the need for an invasive procedure – surgical, diagnostic, or therapeutic – to discharge and beyond. ^{5 (p2)}

We used the PSH conceptual framework as a foundation for the development of our preprocedure COVID‐19 testing team (PCTT). The PSH model recognizes the significance of perioperative leaders’ direction and influence to ensure clear communication among hospital departments to successfully coordinate care. Therefore, the executive perioperative and surgical leaders designated existing preoperative anesthesia clinic leaders to develop the PCTT. The PCTT includes a combination of two RNs and three advanced practice RNs (APRNs) who are experts in preoperative assessment and throughput. The RNs and APRNs in the preoperative anesthesia clinic routinely ensure that all necessary preoperative planning and coordination of care has been completed and documented. By designating the existing preoperative anesthesia clinic leaders to create and lead the PCTT, the executive perioperative leaders were able to support the PCTT with routine, well‐established clinical communication processes to integrate patient care with the necessary departments, including laboratory, scheduling, informatics, surgical, anesthesia, and nursing. Well‐established communication processes with these hospital departments helped us continuously aim to reduce variation in testing practices by coordinating and directing preprocedure testing directly from the PCTT.

PURPOSE OF THE STUDY

Clinical evidence supporting the effectiveness of an intervention is not sufficient to create a public health effect; however, change can be effected by addressing implementation barriers. ⁶ For this reason, we used multiple strategies to reduce barriers for patients in obtaining preprocedure COVID‐19 testing. We aimed to create a highly reliable process for patient preparation and follow‐up for preprocedure COVID‐19 testing 72 hours in advance of anesthesia. This process included personalized communication with patients and their families to guide them to testing resources close to home. Critical to our success was our process for reporting laboratory test results to the perioperative and surgical teams at least 12 hours before elective procedures.

We aimed to create a highly reliable process for patient preparation and follow‐up for preprocedure COVID‐19 testing 72 hours in advance of anesthesia.

HYPOTHESIS

We hypothesized that implementation of a strategy prepared by the PCTT would streamline perioperative care for the scheduled surgical volume while maintaining patient and hospital staff member safety and preserving scarce resources. We further hypothesized that this approach would result in minimizing the surgical cancellation rate, decreasing avoidable delays to patient care, and reducing the rescheduling of elective surgical procedures.

METHODS

We conducted a prospective, observational, mixed‐methods study to explore and integrate the qualitative concepts that we learned from focus groups with the quantitative data to evaluate the effectiveness of a COVID‐19 preprocedure testing strategy to support patient access to surgical resources and mitigate the transmission risk to perioperative staff members and patients in an urban, academic, pediatric tertiary care center with 343 licensed beds. Our surgical patient population includes infants and children from Tennessee and the southeast region of the United States.

Protection of Patient Rights

The Institutional Review Board reviewed our study protocol and granted approval with exempt status. Monitoring and reporting of COVID‐19 testing results 72 hours before elective surgery is a required element of patient preparation, and the PCTT monitors the daily volume of positive and negative tests via a report generated from the electronic medical record (EMR). Positive and negative test result data is collected in aggregate (ie, total number of asymptomatic tests stratified by positive and negative results in each 24‐hour period). The daily de‐identified volume of positive and negative tests is maintained by the PCTT in a VUMC encrypted password‐protected database.

Description of Qualitative Study Procedures

We held focus groups with content experts (eg, pediatric surgeons, anesthesiologists, surgical schedulers, perioperative nurses, hospital leaders) to identify strategic objectives and to develop a reliable centralized process for reporting preprocedural testing results to perioperative and surgical teams. Our interviews revealed that patient education (ie, patient guidance to testing sites that serve pediatric patients) along with an efficient method for test results reporting and communication to perioperative and surgical teams were key to maintaining surgical volumes during the COVID‐19 pandemic. The authors validated the recommendations from the content experts and assessed readiness for adoption of process changes through meetings with perioperative nurses and the surgical scheduling team members.

Data Collection and Analysis

To assess if the PCTT strategy influenced cancellation rates, the authors used the reporting tools in the perioperative scheduling system of the EMR. The scheduling system records each completed and canceled procedure and includes the reason for the cancellation. The authors generated a procedural volume and cancellation report for each procedural area (ie, endoscopy, interventional radiology, interventional cardiology, and the general OR) to compare cancellation rates in the preimplementation and postimplementation periods. A report was generated, and during the preimplementation period (ie, May 4, 2019, to March 23, 2020), the total number of procedures was 22,537; during the postimplementation period (ie, May 4, 2020, to March 1, 2021), the total number of procedures was 18,694. The authors reviewed the volume and cancellation data for each of the four major procedural areas, independently calculated the cancellation percentage for each area, and confirmed the results.

To efficiently monitor and report the status of patients’ asymptomatic COVID‐19 test results to the perioperative and surgical team members before the patient’s surgical encounter, the PCTT collaborated with the VUMC informatics department team members to create customized reporting tools utilizing the EMR. This allowed the PCTT to efficiently view COVID‐19 laboratory test results within the previous 72 hours without having to look up each patient’s results individually. Specific reporting filters allow for information to be summarized by date of service, date of the order for the preprocedure COVID‐19 test, completed or pending status, the procedural location, the testing plan (ie, timing and location), and confirmation that the plan was discussed with the patient’s family. These reporting filters allowed our PCTT team to perform surveillance on each patient and to take early action to minimize delays. The reporting tools in the EMR were critical to our team’s ability to screen 100% of the patients on the surgical and procedural schedule.

For example, if the reporting tool showed that a patient did not have a COVID‐19 test order, our PCTT placed an order and called the patient’s family to guide them to a testing resource. Since a rapid COVID‐19 test was a scarce resource and we were limited to fewer than 10 per day, rapid tests were authorized only for those patients and families who could not reasonably access a COVID‐19 RT‐PCR test because of geographical, transportation, clinical, or social reasons. Therefore, we created a centralized e‐mail address for providers to request a rapid test for patients meeting the criteria. The PCTT reviewed the e‐mails and authorized rapid tests routinely, incorporating this information into the daily COVID‐19 report.

Rapid tests were authorized only for those patients and families who could not reasonably access a COVID‐19 RT‐PCR test because of geographical, transportation, clinical, or social reasons.

Patient and Family Education

To implement preprocedure COVID‐19 testing while avoiding a possible increase in cancellations, we created patient preparation resources that included maps detailing preprocedure COVID‐19 testing sites in Tennessee and in the surrounding states. To offer a variety of communication tools, we created a preprocedure testing web site with information on testing access, types of acceptable COVID‐19 tests, hospital COVID‐19 symptom screening, and visitor policies. We also provided educational brochures that were sent electronically via their patient account (My Health at Vanderbilt). Most importantly, for consistency in our communication, we generated scripts for the surgical schedulers that included detailed testing information and anticipatory guidance for frequently asked questions about hospital safety practices to minimize COVID‐19 transmission. This approach offered reassurance to patients and families that they could trust us to provide the highest quality care in a safe environment despite the pandemic.

Coordinating Care for Patients With COVID‐19

We established a process in which the PCTT communicated positive COVID‐19 test results with the surgeon who determined whether the procedure was nonurgent (and could be rescheduled) or clinically urgent (and should remain scheduled as planned). If the surgeon made the decision to proceed with a procedure on a patient who tested positive for COVID‐19, there was a detailed electronic communication from the PCTT to staff members in the patient admission area and the OR holding room, the lead anesthesiologist, and the surgeon regarding the plan to welcome the patient and their family safely while limiting the patient’s contact with hospital staff members. This coordinated approach helped to minimize any unnecessary contact with patients with COVID‐19 and to ensure safety for staff members, the other patients, and their families.

In accordance with the Centers for Disease Control and Prevention ⁷ recommendations, we created a process for time‐ and symptom‐based clearance for patients who tested positive for COVID‐19 within the past three months because these patients were not likely to be symptomatic or contagious. Preprocedure COVID‐19 testing was discouraged for this patient population because RT‐PCR tests would likely continue to return positive results despite resolution of symptoms. ⁷ We have outlined the screening process for patients who have recovered from COVID‐19 (Figure 1).

Figure 1.

Time and symptom clearance protocol for patients who previously tested positive for COVID‐19 at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN. RT‐PCR = reverse transcription polymerase chain reaction; NP = nurse practitioner; EMR = electronic medical record; PCTT = preprocedure COVID‐19 testing team; PACU = postanesthesia care unit.

We provided secure encrypted electronic reporting of COVID‐19 results to all perioperative team members (eg, RNs, anesthesia professionals, surgeons). The PCTT distributed the report data 12 hours before the next day of service. The report, organized by surgical specialty, included data to identify patients who tested positive for COVID‐19, asymptomatic patients who previously tested positive for COVID‐19, and patients who were preapproved for a rapid COVID‐19 test in OR holding. Additional details related to COVID‐19 such as pending tests, tests from outside facilities, missing tests, and a list of patients who requested to reschedule their surgery also were reported.

RESULTS

The preoperative anesthesia clinic implemented the PCTT strategy on May 4, 2020, and the OR returned to prepandemic daily procedural volumes (80 to 100 procedures) by June 17, 2020 (Figure 2). Before implementing COVID‐19 preprocedure testing, the preoperative anesthesia clinic performed screening and assessment based on consultation requests for only the most medically complex patients (5%) of more than 18,000 scheduled procedures. After implementing preprocedure COVID‐19 testing and the PCTT strategy, 100% of scheduled procedures (N = 18,694) were reviewed and appropriately triaged through the preprocedure testing process. A Tukey’s multiple comparisons test was used for comparison of mean preimplementation (May 4, 2019, to March 23, 2020) and postimplementation (May 4, 2020, to March 1, 2021) cancellation rates in four major procedural areas. Remarkably, there was no significant difference in the percentage of procedures canceled and rescheduled in the four procedural areas when comparing the preimplementation and postimplementation periods (P = .89, 95% confidence interval = −4.29 to 3.09) (Table 1). Only 0.72% of all procedures in the postimplementation period were canceled for a COVID‐19–related reason (Figure 3). A COVID‐19–related reason was defined as parent refusal of preprocedure testing or fear of seeking care during the pandemic. Of the 18,694 procedures tracked in the system, only 3.6% (N = 720) rapid COVID‐19 tests were utilized.

Figure 2.

Results of weekly asymptomatic preprocedure COVID‐19 testing from May 4, 2020, through March 1, 2021, at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN.

Table 1.

Comparison of Preimplementation and Postimplementation Surgical Cancellation Rates (N = 41,231)

Surgical Area	Preimplementation (n = 22,537) a			Postimplementation (n = 18,694) b
	Procedures Scheduled	Cancellations	Rate, %	Procedures Scheduled	Cancellations	Rate, %
Cardiac catheterization	1,038	64	6.2	1,031	81	7.9
Endoscopy	3,095	281	9.1	2,192	209	9.5
Interventional radiology	734	91	12.4	670	85	12.7
OR	17,670	1,635	9.3	14,801	1,393	9.4

^a May 4, 2019, to March 23, 2020.

^b May 4, 2020, to March 1, 2021.

Figure 3.

Comparison of preimplementation and postimplementation cancellation rates (including COVID‐19–related surgical cancellation rate) at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN.

The average asymptomatic COVID‐19 prevalence rate in our pediatric asymptomatic preprocedure testing patient population was 0.83% from May 4, 2020, to March 1, 2021. In October 2021, during the Delta variant peak, the asymptomatic prevalence rate increased to 5.06%; during the Omicron phase in January 2022, the rate reached 18.6%.

DISCUSSION

Although we found an average asymptomatic COVID‐19 prevalence of less than 1% between May 2020 and March 2021, reported prevalence rates vary widely. In India, 21 (8%) of 262 preoperative asymptomatic adult patients tested positive for COVID‐19. ⁸ Anesthesiologists at the University of Iowa documented an asymptomatic COVID‐19 prevalence of 1.3% in their ambulatory surgery patient population. ⁹ A total of 0.13% asymptomatic adults and children at University of California at Los Angeles Health tested positive for COVID‐19 during preoperative testing between April 7, 2020, and May 21, 2020. ¹⁰ These differences in asymptomatic prevalence rates suggest that COVID‐19 incidence varies among communities based on a combination of factors, including vaccination rates, community immunity, presence of COVID‐19 variants, and public prevention practices (eg, masking, physical distancing).

On October 29, 2021, the US Food and Drug Administra‐tion expanded COVID‐19 vaccination eligibility under emergency use authorization for children five years of age and older. ¹¹ As more infants and children become vaccinated, we look forward to better understanding how vaccination influences asymptomatic COVID‐19 prevalence in children. As community immunity further develops, organizations may be able to phase out preprocedure testing. The potential for perioperative respiratory complications because of undetected COVID‐19 infection will likely rise if preprocedure testing is eliminated. ¹² Ongoing study and monitoring of anesthesia or surgical complications will be critical if preprocedure COVID‐19 testing is phased out.

Our PCTT approach has provided our organization with a highly reliable process for preprocedure preparation for COVID‐19 testing and has ensured that all perioperative RNs, anesthesia professionals, and surgical team members start each day knowing the COVID‐19 status of all patients undergoing anesthesia. This program has served to maintain our prepandemic surgical volume of 80 to 100 procedures per day and has minimized patients’ barriers to accessing surgical and procedural care throughout the pandemic. Our process allows for careful planning and preparation to welcome all patients into the perioperative setting while minimizing perioperative team members’ exposure to patients with COVID‐19 and avoiding unnecessary procedural cancellations.

If vaccination rates increase in children, we may restructure the PCTT strategy to meet the changing needs of our pediatric patient population. The PCTT has quickly created and recreated efficient perioperative workflows to meet our patients’ changing needs throughout the pandemic, and these skills will be valuable in the OR holding room, the preoperative testing clinic, and our ambulatory surgery centers.

Decentralizing the Process

Another valid approach for a preprocedure COVID‐19 testing process within a large medical center is for personnel at each individual surgical clinic to screen their patients. To ensure success, we recommend that each surgical clinic designate team members to train and learn the test result reporting tools in the EMR. Additionally, the surgical clinics should create a weekend coverage plan for results monitoring and communication follow‐up for procedures that are scheduled on Mondays. There should be a clear communication pathway for coordinating care for any patient who tests positive for COVID‐19. Finally, we recommend creating an oversight group to ensure standardization of the workflows generated at these various clinics. Clinical guidance for preprocedural testing evolves and changes quickly as we learn more about this disease.

We recommend a centralized PCTT strategy rather than a decentralized process. The PCTT model allows us to quickly adapt our operational processes to align with new clinical guidelines. This approach reduces variability in processes, standardizes reporting procedures, ensures patient satisfaction, and limits procedural cancellations because of inadequate preprocedure preparation. In contrast, decentralizing the process and allowing it to be managed at individual clinics introduces opportunities for variability in follow‐up and may result in inadequate patient preparation and unnecessary procedure cancellations. The PCTT’s ability to achieve a 100% screening rate is because the process has been centralized and standardized to one team with clear accountability for screening each patient before their day of surgery.

LIMITATIONS

Our data set included pediatric patients who had a scheduled surgery. We did not include pediatric patients who did not undergo PCTT screenings, pediatric patients who underwent unplanned or emergent surgery and were admitted to the hospital through the emergency department, or pediatric inpatients who were tested for COVID‐19 upon admission.

Early in the pandemic, one of the greatest barriers to COVID‐19 testing was access to testing locations. Although this has gradually improved as tests have become more widely available, supply chain constraints and staffing limitations intermittently affected access to testing in central Tennessee communities. For those patients and family members who were able to undergo testing at other centers, gaining access to those results within the 72‐hour time limit was a challenge because of variability in laboratory turnaround times. We addressed this gap by allowing for rapid testing onsite the morning of the procedure.

CONCLUSION

From May 4, 2020, to March 1, 2021, our PCTT provided preoperative assessment, reporting, and coordination of care for more than 18,000 infants and children. The implementation of this team has enabled us to maintain our prepandemic surgical volume of 80 to 100 procedures per day by minimizing barriers to COVID‐19 testing. With implementation of our PCTT strategy, we showed successful mitigation of obstacles to preprocedural testing through personalized patient and family education. We maintained operational efficiency throughout the pandemic without an increase in procedure cancellation because of patients testing positive for COVID‐19 on the day of surgery while showing appropriate use of scarce laboratory and personal protective resources. This strategy may be applicable to other ambulatory surgery centers and medical centers, especially as COVID‐19 variants continue to prolong the pandemic. Preprocedure COVID‐19 testing may not be phased out or eliminated in the near future; as such, the PCTT strategy may be helpful at other health care centers.

Key Takeaways.

• When elective procedures resumed in 2020 during the COVID‐19 pandemic, health system leaders at a tertiary pediatric facility instituted safety measures to determine a patient’s COVID‐19 status before surgery by creating a preprocedure COVID‐19 testing team (PCTT). This team worked to streamline preoperative preparation, maintain scheduled procedural volume, and ensure patient and hospital staff member safety.

• All scheduled outpatients were required to have a negative reverse transcription polymerase chain reaction COVID‐19 test conducted within 72 hours of their procedure or a plan to proceed with their procedure despite a positive result. Day‐of‐procedure testing with rapid response tests was provided on admission for those patients who were unable to access pretesting because of geographical, transportation, clinical, or social reasons.

• From May 2020 to March 2021, the PCTT provided education and monitored test results for 18,694 families whose children were undergoing procedures requiring anesthesia. After implementation, 100% of scheduled procedures were reviewed and appropriately triaged through the preprocedure testing process, and there was no significant difference in the percentage of procedures canceled and rescheduled when comparing the preimplementation and postimplementation periods.

• The PCTT provided a highly reliable process for preprocedure preparation for COVID‐19 testing and has ensured that all perioperative RNs, anesthesia professionals, and surgical team members start each day knowing the COVID‐19 status of all patients undergoing anesthesia. This strategy may be applicable to other ambulatory surgery centers and medical centers, especially as COVID‐19 variants continue to prolong the pandemic.

Biographies

Jill S. Kinch, MSN, MMHC, advanced practice RN (APRN), certified pediatric nurse practitioner‐primary care/acute care (CPNP‐PC/AC), nurse executive‐board certified (NE‐BC), is the director of Advanced Practice, Ambulatory, Perioperative and Acute Care Services, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN. Ms Kinch has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.Correspondence: Jill.S.Kinch@vumc.org.

Kim Isenberg, MSN, APRN, CPNP‐PC/AC, NE‐BC, is the manager of Advanced Practice, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN. Ms Isenberg has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Lexie Vaughn, MD, is a resident physician in General Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN. Dr Vaughn has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Barbara Shultz, MSN, RN, nurse executive advanced‐board certification (NEA‐BC), is the administrative director of Surgical Services, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN. Ms Shultz has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Jeffrey S. Upperman, MD, fellow of the American College of Surgeons (FACS), is the surgeon‐in‐chief, professor, and department chair of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN. Dr Upperman has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.